Case Questions

1. Outline the metabolic changes that occur during starvation/inadequate nutritional

intake (not related to disease) that could result in weight loss.
The changes in metabolism that occur during starvation include: an overall
decrease in energy 2 needs, 20-25 kcal/kg/d decrease in metabolic rate, greater than 90%
of kcal come from fat storage, energy from protein is less than 10% for gluconeogenesis,
hormone adaptation preserves protein stores, decrease need for glucose utilization, and
Utilization of lipid as main energy source. Alanine and glutamine

2. Read the consensus of the Academy of Nutrition and Dietetics/American society of

Parental and Enteral Nutrition: Characteristics recommended for the identification
and documentation of adult malnutrition. Explain the differences between
malnutrition associated with acute illness and inflammation.
The Academy’s Evidence Analysis analyzes reduction and/or change in serum
albumin and prealbumin with weight loss in prolonged protein energy restriction anorexia
nervosa, non-malabsorptive gastric partitioning bariatric surgery, calorie restricted diets,
starvations, low-calorie diets, and nitrogen balance. The analysis shows that these acute-
phase proteins do not consistently change with weight loss, calorie restriction, or nitrogen
balance.
They appear to better reflect severity of the inflammatory response rather than
poor nutritional status. This analysis are probable indicators of inflammation, but do not
indicate malnutrition and do not respond to feeding interventions in the setting of active
inflammatory response. Malnutrition related to chronic disease is when inflammation is
constant. Malnutrition related to acute illness and inflammation is when the inflammation
is at a severe level.
Lean body mass reduces over time,
3. Find the current definitions of malnutrition in the United States using the ICD 10
codes. List all of them and describe the criteria for one of the diagnoses.
Malnutrition is diagnosed through the codes of the Clinical Modification of the International
Classification of Diseases (ICD-CM). The 2014 ICD-10-CM diagnosis codes of malnutrition.
i. E40 Kwashiorkor
ii. E41 Nutritional Marasmus
iii. E42 Marasmic kwashiorkor
iv. E43 Unspecified severe protein-calorie malnutrition
v. E44 Protein-calorie malnutrition of moderate and mild degree
vi. E45 Retarded development following protein-calorie malnutrition
vii. E46 Unspecified protein-calorie malnutrition
Malnutrition includes codes E40-E46 and is categorized as type 1 or type 2. Type 1
excludes intestinal malabsorption and squeal of protein-calorie malnutrition, and 3 type 2
excludes nutritional anemias and starvation.
4. Current ICD definitions of malnutrition use biochemical markers as a component of
the diagnostic criteria. Consider the effect inflammation has on visceral proteins
and how that may impact the clinician’s ability to diagnose malnutrition. Discuss
the following clinical findings and relate to inflammation and ability to diagnose
malnutrition.
- Inflamed body will reduce the production of albumin and prealbumin and cytokines,
IL-1,IL-6, 2 necrosis factor inhibits the factor of proteins.

5. Mr. Campbell was ordered a mechanical soft diet when he was admitted to the
hospital. Describe how his meals will be modified with this diet order.
A mechanical soft diet is designed for individuals who have difficulty chewing or
are unable to eat hard foods. Foods are mechanically altered by whipping, blending,
grinding, chopping, or mashing, to allow the food to be swallowed safely. This diet is
designed to prevent individuals from tiring, allowing them to eat more and obtain the
nutrients they need. This includes food being chopped, ground, and pureed with no need
for a knife. This diet will allow Mr. Campbell to eat more and obtain the nutrients he
needs to heal his body.

6. What is the ensure complete supplement that was ordered? Determine the
additional options for Mr. Campbell that would be appropriate for a high calorie,
high protein beverage supplement.
Ensure Plus is a ready-to-drink, oral nutritional supplement for people with, or at
risk of developing, disease-related malnutrition. Each 8-fluid ounce bottle contains 350
kcal, 13 grams of protein, 50 grams of carbohydrates, and 11 grams of fat. Additional
ready-to-drink nutritional supplement options for Mr. Campbell would include: Boost
Plus or Carnation Instant Breakfast Plus. Boost Plus contains 360 kcal, 14 grams of
protein, 45 grams of carbohydrates, and 14 grams of fat per 8 fluid ounce bottle.
Carnation Instant Breakfast Plus contains 375 kcal, 13.1 grams of protein, 44.1 grams of
carbohydrates, and 16.2 grams of fat in each 8-fluid ounce serving.

7. Assess Mr. Campbell’s height and weight. Calculate his BMI and % usual body
weight.
Mr. Campbell’s height is 6’3” and he has a current weight of 156 pounds.
• Weight= 156 lbs./2.2kg= 70.9 kg
• Height= 75 inches x .0254m= 1.9m
• BMI= 70.9 kg/1.9m2 = 19.6 kg/m2
BMI of 18.5-24.9 indicates a normal weight
• UBW= (156 lbs./220 lbs.) x 100= 70.9%
Weight change= (220 lbs.-156 lbs./220 lbs.) x 100= 29.1%
 8. After reading the physicians history and physical, identify any signs or symptoms
that support the diagnosis of malnutrition using the proposed definitions of
malnutrition by AND/ASPEN malnutrition guidelines.
Identification of two or more of the follow characteristics is recommended for the
diagnosis of adult malnutrition: insufficient energy intake, weight loss, loss of muscle
mass, loss of subcutaneous fat, localized or generalized fluid accumulation that may
sometimes mask weight loss, and diminished functional status as measured by hand grip
strength. In Mr. Campbell’s history and physical, it is indicated that he has lost weight,
that he feels weak, and that he does not have the energy to do anything. The physical
indicates that the patient looks cachectic and appears older than his current age. His
neurological strength is reduced, he has declined muscle tone and his blood work is low
which is related to malnutrition. Respiration was shallow and temperature was low, plus
1 edema, dry skin, temporal wasting.

9. Evaluate Mr. Campbell’s initial nursing assessment. What important factors noted
in his nutrition assessment may support the diagnoses of malnutrition?
In the past 1-2 years, Mr. Campbell has lost over 60 lbs. and is 70.9% of his usual
body weight. Mr. Campbell’s intake percent of meals is indicated at less than 5%, with
sips of liquids. The patient’s recommended fluid requirements are 2000-25000 mL/day;
but he is only consuming 360 mL without I.V. intervention. Mr. Campbell’s intake has
been unsatisfactory to meet the required nutritional status.

10. What is a Braden Score? Assess Mr. Campbell’s score. How does this relate to his
nutritional status?
A Braden scale is used to score a patient’s level of risk for developing pressure
ulcers. The Braden Scale measures six risk factors: sensory pressure, moisture, activity,
mobility, nutrition, and friction/shear, which are scored on a scale of 1-4. Total scores
range from 6-23. The subscales measure functional capabilities of the patient that
contribute to either higher intensity and duration of pressure, or lower tissue tolerance for
pressure. Lower levels of functioning indicate higher levels of risk for pressure ulcer 9
development. Mr. Campbell’s Braden score was measured at a 17, suggesting that he is at
low risk for developing a pressure ulcer.

11. Identify any signs (including laboratory values) or symptoms from the physician’s
history and physical and from the nursing assessment that are consistent with
dehydration.
In Mr. Campbell’s assessment, he expresses that he feels lethargic and it is indicated that his skin
displayed tenting during a skin turgor test. His nutrition assessment states that Mr. Campbell is
only meeting 360 mL of his 2000-2500mL fluid requirements. Mr. Campbell’s lab results are
also consistent with dehydration, with elevated sodium and chloride levels, and low potassium
and calcium levels. Elevated sodium levels can indicate increased fluid loss and elevated
chloride levels can indicate metabolic acidosis, which can result from severe dehydration. Mr.
Campbell also has increased BUN and creatinine serum levels. His urinalysis indicated slightly
elevated specific gravity, also indicative of dehydration.

12. Determine Mr. Campbell’s energy and protein requirements. Explain the rationale
for the method you used to calculate these requirements.
The usual protein requirements can be met with 1.0-1.5 g protein/kg/day For Mr.
Campbell’s energy requirements, his current weight of 70.9 kg and multiplied that by 22
and 25 kcal/kg, to establish his estimated minimum and maximum requirements, Mr.
Campbell’s protein needs were estimated to be 1.5-2.0 g protein/kg of his current body
weight.
1.5g x 70.9 kg = 106.4 grams
2.0g x 70.9kg = 141.8 grams
His protein intake should range from 106.4 to 141.8 grams based on his intake
level.
25-35 KCAL ENERGY
1.2-1.75 PROTEIN
13. Determine Mr. Campbell’s fluids requirements. Compare this with the information
on the intake/output report.
Mr. Campbell’s estimated dietary intake is a total of 582 calories, 30 grams of protein, 72
grams of carbohydrates, and 30% of his total calories came from fat. Mr. Campbell
consumed over 1,000 less calories than his recommended amount of 1,850-2,050
kcal/day and he needed to consume 103 grams more of protein to meet his minimum
estimated requirements.
1ML OF FLUID FOR EACH CALORIE = Mr. Campbell’s
14. From the nutrition history assess Mr. Campbells usual dietary intake. How does this
compare to the requirements that you calculated for him? Can your evaluation of
his dietary intake contribute to the evidence for diagnosing malnutrition?
Mr. Campbell’s estimated dietary intake was calculated through the SuperTracker.
 Egg 70 calories 6g protein
 Coffee 5 calories
 ½ slice of toast 52 calories 9g protein
 Ensure complete 220 calories 9g protein
 Soup ½ cup 59 calories .9g protein
 ½ cup milk 62 calories 4g protein
 Ground turkey 94 calories 15g protein
 Mashed potatoes 59 calories 1g protein
 = 621 calories and 38g of protein
He is consuming less than the recommended amount of 1850-2050 kcal/day and 103g of protein.
Use a fitess app to track his

15. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses
and write at least two PES statements with one focused on the clinical domain.

Malnutrition related to squamous cell carcinoma of Tongue as evidenced by

patient’s unintentional weight loss of 29.1% of his usual body weight in the past 2 years,
patient’s deficient energy intake over the past several months, patient’s lack of appetite,
patient’s decreased muscle tone and loss of lean mass, patient’s failure to consume
estimated needs from diet, and patient’s partial glossectomy 5 years ago.
Unintended weight loss related to client’s inability to consume sufficient energy as
evidenced by a 29.1% weight change within the last two years, client’s decreased appetite over
the last several months, patient’s decreased muscle tone and loss of lean mass in his quadriceps
and gastrocnemius, and patient’s partial glossectomy 5 years ago.

16. Determine the appropriate intervention for each nutrition diagnosis.

Since Mr. Campbell is cannot to meet his nutritional needs through the oral route,
enteral nutrition (EN) is needed and must be started within 48 hours following admission.
The goals of therapy are to maintain healthy lean body mass and body fat. Enteral
nutrition is necessary to help him meet his needs, regain lean body mass, and promote
healthy weight gain to reach his ideal body weight. Since Mr. Campbell has been
consuming small quantities of food orally, I would also order Mr. Campbell to a level 1
mechanical soft diet, to encourage him to meet the rest of his needs through oral intake. I
would recommend for him to drink lots of fluids and continue to consume a nutritional
beverage supplement.

17. Identify the steps you would take to monitor Mr. Campbell’s nutritional status
while he is hospitalized?
While Mr. Campbell is hospitalized, it is important to monitor his weight, his albumin levels,
and his oral versus enteral calorie intake. When providing follow-up, the focus would be to
monitor his weight and evaluate his calorie intake to ensure he is meeting his nutritional
needs, gaining appropriate weight, and rebuilding muscle.

18. Write down your ADIME note for this initial assessment for Mr. Campbell.
A. Assessment:
68 yo male Patient admitted to acute care for possible dehydration, weight loss,
generalized weakness, and malnutrition. Patient ordered to receive 0.9% sodium chloride with
potassium chloride 20 mEq 125 mL/hr and vancomycin 1 g in dextrose 200 mL IVPB.
Height: 6’3” Weight: 156# BMI: 19.6 kg/m216
Physical assessment: decreased strength; decreased muscle tone with normal ROM; loss of lean
mass noted; skin turgor TENT; Braden score 17
B. Diagnosis:
Malnutrition related to chronic disease squamous cell carcinoma of tongue as evidenced by
patient’s unintentional weight loss of 29.1% of his usual body weight in the past 1-2 years,
patient’s insufficient energy intake over the past several months, patient’s lack of appetite,
patient’s 17 decreased muscle tone and loss of lean mass , and patient’s prealbumin level of 9
mg/dL, and glossectomy 5 years ago.

C. Intervention:
Begin patient on enteral nutrition, Mr. Campbell will be eventually progressed to bolus
feedings. This will provide him with 1,800 kcal, 80 grams of protein, 240 grams of
carbohydrates, and 58.5 grams of fat to meet the rest of his recommended needs. Mr. Campbell
will be ordered a level 1 mechanical soft diet and encouraged to consume Ensure Plus, Boost
Plus or Carnation Instant Breakfast Plus. Overall, the goal is to normalize and increase his
weight to reach his ideal body weight of 196 lbs.

D. Monitoring/Evaluation:
Mr. Campbell renal function will be monitored to ensure his kidneys can handle the amount of
protein recommended. It will be evaluated through urine and creatinine serum levels. His weight
will have to be monitored to see if he is progressing towards his ideal body weight.